ED ‘checkout’ adds $1 million in revenue

Less risk of violations

A third of patients seen at one Arizona emergency department (ED) were uninsured, but this percentage was cut in half after a “checkout” process was implemented, reports Todd B. Taylor, MD, FACEP, a Phoenix, AZ-based consultant specializing in Emergency Medical Treatment and Labor Act (EMTALA) compliance.

“We essentially changed our demographic, by helping eligible patients enroll in Medicaid,” he says. “It resulted in about $1 million in additional revenue with almost no additional cost, which is virtually unheard of in healthcare.”

Almost half of uninsured patients “are not truly indigent; they are just uncooperative,” according to Taylor. “This is an opportunity to apply the appropriate incentive, and I believe it’s a unique opportunity that doesn’t exist in a doctor’s office.”

Though many ED registrars collect copays after the medical screening examination (MSE) but before the patient is discharged, Taylor recommends doing this step only at the end of the visit, acknowledging that this change might cause problems with patient flow. “The problem is that patients are discharged in waves. So registrars may be sitting with nothing to do when they could be collecting copays,” he says.

At the end of the ED visit, patients often walk out without paying copays, adds Taylor. “Most EDs have a quick and easy exodus, with no process in place to be sure the patient goes through checkout once the medical care is completed,” he says.

The checkout person should be able to handle registration and financial counseling, says Taylor, with “the ability and the authority” to make arrangements for payment, including completing Medicaid applications if appropriate.

Information verified

In one case, an ED patient’s bills kept getting returned due to an inaccurate address: the hospital’s.

“Somebody had just typed it in, and it was never updated,” says Taylor. “You would be amazed the times people will just give you an address for a vacant lot.”

At checkout, the registrar also has the opportunity to verify that a patient’s Social Security number, address, and phone number are legitimate. “The ED is a big victim of theft: people who can pay, but simply choose not to. Very little effort goes into preventing that,” says Taylor.

Checkout also is a good time to ask the patient, “Do you have any questions that were not answered?” “Did you get your discharge instructions?” and “Do you have any concerns about your care today?”

“Complaints usually come about a month or two later, when the patient gets the bill or it gets turned over to collections,” says Taylor. “If you give that person the chance to bring up any issue at that moment in time, it can be addressed before they leave.”

Some of the hospital’s managed care contracts stated that if the copay wasn’t collected at the time of the visit, then the patient couldn’t be billed for it, adds Taylor. “This was money that was just being thrown away, because we didn’t understand the system,” he says. “We went from collecting $1,000 a month to $100,000 a month.” (See related story on how one ED doubled collections, below.)